Microsoft Word - Cataract+Surgery+Direct+Referral+Form[1 ...



Optometrist direct referral for cataract surgery plus choice

Patient NHS Number:

| |Patient |GP |Optometrist |

|Name | | | |

|DOB | | | |

|Address | | | |

| | | | |

| | | | |

| | | | |

|Postcode | | | |

|Telephone | | | |

|email | | |GOC No: 01- |

Surgery required on: - Tick appropriate boxes - First eye Second eye Right eye Left eye

|Refractive Status |Right eye |Left eye |

|Unaided vision | | |

|Best corrected VA |Monocular: PH: |Monocular: PH: |Binoc: |

|Refraction | /- | /- |

|Historical BCVA; Date: / / | | |

Ophthalmic history: Tick where appropriate

|Previous Cataract surgery; Date / / |R |L |Refractive surgery (Px to bring pre & post details to clinic) |R |L |

|Squint / Previous squint surgery |R |L |Amblyopia |R |L |

|Retinal detachment |R |L |Glaucoma |R |L |

|Trauma |R |L |Keratitis |R |L |

|AMD |R |L |Iritis |R |L |

|Other eye surgery or comments: |

| |

General Medical Risk Factors: Tick where appropriate

|Hypertension (must be controlled for surgery) | |Parkinsons | |

|Diabetes (must be controlled for surgery) | |Tamsulosin/Doxazosin | |

|Anticoagulant | |Heart Disease / Heart Surgery | |

|Breathing Problems | |Stroke | |

|Medications (including any eye drops): |Allergies: |

| | |

Ocular Examination: Tick where appropriate

|Aperture: |

General Factors: Tick as appropriate

|Difficulty lying flat & still for surgery | |Slit lamp exam difficult | |

|Previous Reaction on local anaesthetic | |Wheelchair user or poor mobility | |

|Nervous / Anxious / Claustrophobia | |Poor understanding of English | |

Criteria for 1st and 2nd eye cataract surgery

Ipswich and East Suffolk CCG and West Suffolk CCG will only fund cataract surgery when the following criteria are met:

The patient should have sufficient cataract to account for the following visual symptoms as evidenced in the Cataract Referral Form:

• Blurred or dim vision with a corrected binocular distance acuity of 6/10* (0.20 logMAR) or worse OR

• Blurred or dim vision with a corrected monocular distance acuity of 6/18 (0.40 logMAR) or worse OR

• Anisometropia - refractive difference between the two eyes (≥3) resulting in poor binocular

vision or disabling diplopia which may increase the risk of falls

AND

• The cataract should affect the patient’s lifestyle scoring ≥3 as evidenced in the Cataract

Assessment Form (below)

AND

• The patient has waited 7 days to make a decision and wishes to undergo cataract surgery

and understands the risks and benefits of this surgery.

*6/10 equates to 6/9-2 on Snellen chart

Patients need to evidence how cataract is affecting daily activity. A patient needs to score ≥3

|1. Visual disability |Please Tick |Score |

|Affected by glare | |2 |

|Difficulty with reading | |1 |

|Difficulty watching television | |1 |

|Difficulty performing work or hobbies | |1 |

|2. Social functioning (Tick ONE box only) | | |

|Lives alone | |2 |

|Cares for partner | |2 |

|Lives in sheltered accommodation | |1 |

|Lives with carer | |1 |

|Lives in a residential or nursing home | |1 |

|3. Other | | |

|Drives a car/is in paid employment | |1 |

|Mild/moderate hearing impairment | |1 |

|Severe hearing impairment (Deaf) | |2 |

|Has fallen twice or more in the last 12 months | |2 |

|Total Score | | |

Choice of provider service:

Leaflets given to patient: Cataracts and Cataract Surgery – A guide to your choice of hospital

Patient preferred hospital:

Patient – I have had the benefits and risks of cataract surgery explained to me, and want NHS surgery at this time, at the above hospital:

Yes No

I agree/do not agree that any Ophthalmologist to whom I am referred may make information relevant to my eye condition and its treatment available to my Optometrist/OMP. I understand that the final decision on whether or how surgery is approached rests with the surgeon.

Date………………………

Patient’s signature………………………………………………...………………………………….

Print Name …………………………………………………………………………………………………………….

Optometrist’s signature……………………………………………………...……… Date………………………….

Print Name………………………………..……………………………………………….

Instruction to optometrist: Fax this completed form to Evolutio on 0333 240 7729 & send a copy to GP

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